Healthcare Provider Details

I. General information

NPI: 1285149500
Provider Name (Legal Business Name): BRETT RUSSELL LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 SE MARLIN AVE
WARRENTON OR
97146-9624
US

IV. Provider business mailing address

960 SW CEDAR DR
WARRENTON OR
97146-9749
US

V. Phone/Fax

Practice location:
  • Phone: 503-861-4276
  • Fax:
Mailing address:
  • Phone: 503-298-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: